1336104462 NPI number — SMITH TRYON FAMILY HEALTH INC D.B.A. BLUE WATER MEDICAL

Table of content: (NPI 1336104462)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336104462 NPI number — SMITH TRYON FAMILY HEALTH INC D.B.A. BLUE WATER MEDICAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SMITH TRYON FAMILY HEALTH INC D.B.A. BLUE WATER MEDICAL
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336104462
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/27/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1990 MCCULLOCH BLVD N
Provider Second Line Business Mailing Address:
SUITE D, BOX 379D
Provider Business Mailing Address City Name:
LAKE HAVASU CITY
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86403-5749
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-453-6963
Provider Business Mailing Address Fax Number:
928-453-7015

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1801 MESQUITE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE HAVASU CITY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86403-5664
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-453-6963
Provider Business Practice Location Address Fax Number:
928-453-7015
Provider Enumeration Date:
04/20/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SMITH TRYON
Authorized Official First Name:
ELIZABETH
Authorized Official Middle Name:
ANNE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
928-453-6963

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  35026 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X , with the licence number: 35026 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X , with the licence number: 2768 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)